ABSTRACT: We report a case of the spontaneous formation of a left anterior descending artery to right ventricular fistula. The unprovoked appearance of this fistulous connection was clearly documented by serial angiography and confirmed during surgery.

ABSTRACT: We report on 2 patients with cerebrovascular events associated with sexual activity and PFO who subsequently underwent endovascular patent foramen ovale (PFO) closure. The concurrence of sexual activity (a Valsalva equivalent) at symptom onset, together with supporting data — prior paradoxical embolus in 1 case, elevated D-dimer in another — supported paradoxical embolization as the most likely mechanism of the cerebrovascular events. These cases emphasize that clinicians evaluating patients for PFO closure should explicitly inquire about sexual activity at stroke onset.

ABSTRACT: Ostial coronary disease presents a challenge from multiple perspectives with regard to percutaneous intervention. We present a novel case of a technically challenging ostial right coronary artery calcified lesion with a bar of calcium at the aorto-ostial junction which prevented intubation with multiple guiding catheters. We describe the use of a “buddy wire” as a technique for “focused-force” angioplasty with slow incremental balloon inflation of increasing diameter for plaque modification prior to stenting in a situation where rotational atherectomy and cutting balloon angioplasty were not an option.

ABSTRACT: The current treatment of massive pulmonary embolism (PE) has been either thrombolysis or surgical embolectomy. Percutaneous rheolytic thrombectomy, however, has emerged as an alternative treatment in patients with contraindications to thrombolysis. This case illustrates the usefulness of the AngioJet® thrombectomy catheter in patients with contraindications to thrombolytics. Three-dimensional computed tomography imaging demonstrated the effectiveness of treatment in this patient with massive PE.

ABSTRACT: This paper provides a comprehensive up-to-date review of the medical and invasive management of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). The authors have summarized findings from key clinical trials published recent years that contribute to clinicians’ understanding of how best to optimize therapy. The goals for the management of NSTE-ACS are rapid and accurate risk stratification, appropriate and institution-specific triage to interventional versus medical strategies and optimal pharmacologic therapy — all of which provide for a smooth and seamless transition of care between the emergency department and the cardiology service. High-risk features or absolute treatment trigger criteria that support more aggressive medical therapy (i.e., addition of small-molecule GP IIb/IIIa inhibitor to a core regimen of aspirin, enoxaparin, and in most cases, clopidogrel) and/or that would direct clinicians toward percutaneous, mechanical/interventio

ABSTRACT: This paper provides a comprehensive up-to-date review of the medical and invasive management of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). The authors have summarized findings from key clinical trials published recent years that contribute to clinicians’ understanding of how best to optimize therapy. The goals for the management of NSTE-ACS are rapid and accurate risk stratification, appropriate and institution-specific triage to interventional versus medical strategies and optimal pharmacologic therapy — all of which provide for a smooth and seamless transition of care between the emergency department and the cardiology service. High-risk features or absolute treatment trigger criteria that support more aggressive medical therapy (i.e., addition of small-molecule GP IIb/IIIa inhibitor to a core regimen of aspirin, enoxaparin, and in most cases, clopidogrel) and/or that would direct clinicians toward percutaneous, mechanical/interventio

ABSTRACT:Background. Late mortality among dialysis patients undergoing PCI with bare-metal stents is high. The impact of drug-eluting stent use on outcomes in such patients is unclear. Objective. To compare the clinical outcomes of dialysis patients undergoing coronary stenting with versus without the use of drug-eluting stents. Methods. Baseline features and outcomes were compared in dialysis patients undergoing coronary stent implantation using either bare-metal devices only (n = 41) or drug-eluting stents (n = 33), in recruitment waves 3 (2001–2002; n = 2,047) and 4 (2004; n = 2,112) of the National Heart Lung, and Blood Institute Dynamic Registry. The primary study endpoint was the composite of major adverse cardiac events (MACE), defined as death, myocardial infarction (MI) or any repeat revascularization procedure at 1-year follow up. Results. Baseline and procedural features and in-hospital MACE rates were similar in both groups. Cumulative 1-year rates of the composite M

ABSTRACT: Objectives. Three cases of severe, diffuse coronary artery spasm after drug-eluting stent placement at our institution prompted this review. Background. Drug-eluting stents have gained widespread use due to extraordinarily low rates of restenosis. Despite these generally superior clinical outcomes, the specter of rare idiosyncratic reactions remains a concern. Methods. We performed searches of Medline and the U.S. FDA Manufacturer And User facility Device Experience database (MAUDE) to identify and describe spasm after coronary stent placement. Searches included drug-eluting and bare-metal stents. Institutional cases are reviewed. Location, time course and outcome of cases are described. Results. Thirteen cases of spasm were identified after stent placement. Seven cases occurred after Cypher™ drug-eluting stent placement, 2 after Taxus® drug-eluting stent placement, 1 after BiodivYsio™ and 3 after bare-metal stents. Five patients experienced diffuse, multivessel spasm

ABSTRACT: Endovascular lead infection is an uncommon but serious problem. Transesophageal echocardiography (TEE) is a useful tool for identification of pacemaker lead vegetations. Additionally, incidental echogenic masses are occasionally identified by TEE. The prognosis and optimal treatment of either suspected lead infection or an incidental mass is poorly understood. Objective. The purpose of this study was to examine the incidence and clinical course of pacemaker lead masses. Methods. A total of 1,569 sequential TEE examinations performed from January 2002 to January 2005 were reviewed. Retrospective chart analysis of patients with a pacing lead-associated mass was performed to review the indication for TEE as well as clinical management. Telephone follow up was also performed. Results. During 125 TEE examinations, pacemaker leads were visualized in the right-sided chambers. Fifteen studies demonstrated an echogenic mass associated with the lead. In 9 of these studies, endoc

ABSTRACT: Background. Abciximab is often used to treat high-risk patients during percutaneous coronary intervention (PCI). Recent data indicate, however, that upstream and postprocedural treatment with low-dose glycoprotein (GP) IIb/IIIa inhibitors may be more beneficial than abciximab during and after PCI. Whether abciximab can be used safely or effectively during PCI for high-risk patients after upstream treatment with eptifibatide in patients with acute coronary syndromes (ACS) is not known. Methods. Clinical outcomes were evaluated in 289 patients with ACS who had upstream treatment with eptifibatide, and abciximab (EA) during PCI, and compared to 560 ACS patients who had both upstream and interventional treatment with eptifibatide (EE). Results. Bleeding and vascular complications of the two groups were similar. Overall, 1-year major adverse cardiac event (MACE) rates were similar: 26.0% in the EA group and 25.2% in the EE group; p = 0.82. In patients with unstable angina,